Delayed surgery may warrant lower risk of residual shunt but pay an high risk of hemodinamic worsening also when IABP is promptly instituted. ECMO and MCS may warrant optimal haemodynamics to patients arriving to surgery in cardiogenic shock. Do we need to consider this escalation when IABP is not sufficient to delay surgery? When and how do we should revascularize those patients?
There is some personal report about cases treated with percutaneous angioplasty with implant of stents associated with percutaneous closure of VSD using CERA or Amplatzer muscular ventricular septal defect occluder. The doctors report me that there is residual shunt but the clinical improvement is immediate and save the patient. These are isolates reports, but I think that is a possibility in dramatic cases as VSD in acute infaction.
In my opinion, the option to use ECMO when you meet a very unstable patients is very useful. I personally have treated some patients with huge posterior VSD (the worst type) after 6 days of ECMO. The aim is to buy time to remodel the haemorragic site of myocardium and to warrant a good operation with very low risk of residual shunt
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